Traumatic rupture of the thoracic aorta: A life-threatening emergency and the role of endovascular repair

Traumatic rupture of the thoracic aorta is a rare condition, with a high mortality rate. Over the last 2 decades, strategies for managing aortic injury caused by blunt chest trauma have changed substantially, resulting in significantly improved outcomes. The recent development of endovascular repair offers a less invasive alternative to conventional open repair, particularly in patients with multiple injuries. Here, we report the case of a 31-year-old man who was referred to our emergency department with blunt chest trauma following a motorcycle-truck collision. Computed tomography confirmed acute traumatic rupture of the thoracic aorta, and the patient was successfully treated with endovascular repair

Pulmonary artery penetration due to fish bone ingestion: A rare case report

Accidental fish bone ingestion is a common manifestation at emergency departments. In most cases, ingested foreign bodies usually pass uneventfully through the gastrointestinal tract and complications only present in less than 5% of all patients. In this report, we present the first documented case of pulmonary artery injury due to a fish bone in a 63-year-old male patient hospitalized with hemoptysis after accidentally swallowing a fish bone 30 days ago. This patient subsequently had surgery and endoscopy to safely remove the foreign body and then recovered well on a follow-up examination. For cases of fish bone ingestion, contrast-enhanced chest computed tomography is one of the most essential tools to assess vascular problems and associated mediastinal infections-risk factors for life-threatening and long-term recurrent inflammation. Reconstructing planes along the foreign body axis and changing windows when analyzing CT scans is necessary to avoid missing lesions and dilemmas

Endovascular intervention with high-flow priapism: A case report

High-flow priapism is a rare condition in the form of priapism unrelated to sexual stimulation. The disease causes a decline in quality of life and has the risk of causing long-term erectile dysfunction if not treated promptly. We report a case of a 48-year-old male patient with prolonged high-flow erection after trauma who received endovascular intervention with n-butyl-2 cyanoacrylate biological glue. Results after 40 days of intervention and use of sildenafil 25 mg/day, the patient has an erection and has normal sexual activity. Cavernous arteriovenous fistula causing priapism with high flow is a rare condition. Computed tomography helps supplement information about feeding vessels as well as accompanying injuries for comprehensive assessment before treatment. Currently, there are many treatment methods, but transcatheter arterial embolization is modality of choice for achieve clinical efficacy and can safely and flexibly reduce the risk of secondary erectile dysfunction

Cushing's syndrome due to atypical carcinoid of the mediastinum

Ectopic Cushing's syndrome, caused by a neuroendocrine tumor (NET), is a rare finding. NETs of the mediastinum are extremely rare. NETs arising from the anterior mediastinum are generally aggressive. They are widely characterized at clinical presentations, and may be asymptomatic or present with atypical symptoms. Prognosis is often poor due to their local recurrence and distant metastasis despite a multimodal approach. A 33-year-old male patient was admitted to our department with a femoral soft tissue abscess, diabetes, and hypokalemia. He had no typical features of Cushing's syndrome. However, with a few simple tests, that is, a basal hormone profile, and low-dose and high-dose dexamethasone suppression tests, we diagnosed this complicated condition of ectopic adrenocorticotrophic hormone (ACTH) secretion. Thoracic computed tomography revealed an anterior mediastinal mass of 35 × 22 mm. A surgical excision of the tumor was proposed, and intra-operative pathology consultation returned positive for the suspected NET. Immunohistochemically, the tumor cells were positive for CK, CD56, Chromogranin, Synaptophysin, S100, and CD117. No thymic tissue was found. The Ki-67 was 4%. A diagnosis of primary NETs of the mediastinum, intermediate grade (G2), of atypical carcinoids according to WHO 2015 was established. This patient survived with no sequelae, no distant metastasis, no recurrence, and without adjuvant radiotherapy or chemotherapy 2 years after surgery thanks to earlier diagnosis and prompt surgical intervention. Mediastinum ectopic ACTH-secreting tumors are a rare type of cancer. According to recent research, these tumors frequently display more aggressive behavior and are linked to endocrinopathies. It is noted that patient might have a better outcome and a longer survival time due to earlier detection and complete resection of malignancies

Improving Communication in the Operating Room: Interprofessional Simulation Training for General Surgery and Anesthesiology Residents

Background: Bridging the communication gap between General Surgery and Anesthesiology residents is critical for enhancing team performance in emergent situations within the perioperative setting. Historically, these residents have practiced simulation training independently, despite the necessity for interprofessional collaboration in their daily practice. This disconnect can lead to compromised patient safety, poor work relations, and physician burnout. Description of the Project: To address this, we introduced an interprofessional simulation training program. The program utilizes high-fidelity mannequins for anesthesiology training and box trainers or live pigs for surgical training. Designed to be appropriate for various training years (Table 1), the simulations were written by anesthesia attendings and residents to focus on joint decision-making, enhancing communication, camaraderie, confidence, and respect among participants. General surgery attendings collaborated with the authors to ensure final simulations were of appropriate complexity and included actionable surgical concerns. Funding is supported by a $10,000 Academy of Clinician Scholars grant. Lessons Learned/Expected Outcomes: Post simulation surveys include the NASA Task Load Index (TLI) and questions related to perceived team performance. The TLI is used to measure the effectiveness of the purposefully induced stress response. The remaining questions will be used to assess participants’ perception of their communication, camaraderie, confidence, respect, and understanding of the skills of other team members in the perioperative environment. Longitudinal participation is expected to show significant differences where a single interprofessional simulation event may not. The first series of simulations are incomplete with live animal sessions pending. Once completed, TLI values from live pig sessions will be compared to sessions when they were unavailable or inappropriate. Live animal simulations are expected to increase the stress response of all participants.No statistically significant differences were observed nor expected with current sample size (62 survey respondents, 45 anesthesia, 17 general surgery). However, interim data analysis does suggest emerging trends. Reported mental demand, temporal demand, effort, and frustration on the TLI decreased with seniority (Figure 1). Surgery reported lower mental demand, temporal demand, effort, and frustration but higher performance demand than anesthesia (Figure 2). Average scores within specialties showed: decreased temporal demand with increased anesthesia year; increased physical and performance demand with surgical year. The data revealed trends of increasing measures of perceived team performance with class year in nearly all categories (Figure 3). No overall trends were observed between specialties (Figure 4). However, increasing averages were observed in all categories when comparing within specialties. Recommendations/Next Steps: The project will continue over multiple years to assess longitudinal interprofessional simulation training on medical education. Additional specialties, starting with OB/GYN in the ’24-’25 academic year, will be incorporated. Annual interim data analyses will ensure the program's adaptability and effectiveness. Continuous improvement in simulation scenarios and training methods will be prioritized, with the ultimate goal of establishing a best-practice model for interprofessional simulation training in medical education. This model will be made available to simulation programs at other institutions via a Joint Simulation textbook with Springer Nature. References: Not applicable. All content is original authorship by the project team

Large intra-abdominal venous malformations in associated with inferior vena cava aneurysm

Intra-abdominal venous malformations and inferior vena cava aneurysms are rare and difficult to diagnose because of their nonspecific clinical symptoms. These vascular anomalies are important entities due to the risk of thrombosis or rupture. According to the classification of International Society for the Study of Vascular Anomalies, venous malformations are classified as low-flow vascular anomalies, showing absence of arterial and early venous enhancement and slow gradual filling with contrast on delayed venous imaging. Phleboliths related to thrombosis and calcifications, are the key finding of venous malformations. In this article, we report an exceptional case of large intra-abdominal venous malformations in associated with an inferior vena cava aneurysm

Brief Report: Comprehensive Clinicogenomic Profiling of Small Cell Transformation From EGFR-Mutant NSCLC Informs Potential Therapeutic Targets

Introduction: NSCLC transformation to SCLC has been best characterized with EGFR-mutant NSCLC, with emerging case reports seen in ALK, RET, and KRAS-altered NSCLC. Previous reports revealed transformed SCLC from EGFR-mutant NSCLC portends very poor prognosis and lack effective treatment. Genomic analyses revealed TP53 and RB1 loss of function increase the risk of SCLC transformation. Little has been reported on the detailed clinicogenomic characteristics and potential therapeutic targets for this patient population. Methods: In this study, we conducted a single-center retrospective analysis of clinical and genomic characteristics of patients with EGFR-mutant NSCLC transformed to SCLC. Demographic data, treatment course, and clinical molecular testing reports were extracted from electronic medical records. Kaplan-Meier analyses were used to estimate survival outcomes. Next generation sequencing-based assays was used to identify EGFR and co-occurring genetic alterations in tissue or plasma before and after SCLC transformation. Single-cell RNA sequencing (scRNA-seq) was performed on a patient-derived-xenograft model generated from a patient with EGFR-NSCLC transformed SCLC tumor. Results: A total of 34 patients were identified in our study. Median age at initial diagnosis was 58, and median time to SCLC transformation was 24.2 months. 68% were female and 82% were never smokers. 79% of patients were diagnosed as stage IV disease, and over half had brain metastases at baseline. Median overall survival of the entire cohort was 38.3 months from initial diagnoses and 12.4 months from time of SCLC transformation. Most patients harbored EGFR exon19 deletions as opposed to exon21 L858R alteration. Continuing EGFR tyrosine kinase inhibitor post-transformation did not improve overall survival compared with those patients where tyrosine kinase inhibitor was stopped in our cohort. In the 20 paired pretransformed and post-transformed patient samples, statistically significant enrichment was seen with PIK3CA alterations (p = 0.04) post-transformation. Profiling of longitudinal liquid biopsy samples suggest emergence of SCLC genetic alterations before biopsy-proven SCLC, as shown by increasing variant allele frequency of TP53, RB1, PIK3CA alterations. ScRNA-seq revealed potential therapeutic targets including DLL3, CD276 (B7-H3) and PTK7 were widely expressed in transformed SCLC. Conclusions: SCLC transformation is a potential treatment resistance mechanism in driver-mutant NSCLC. In our cohort of 34 EGFR-mutant NSCLC, poor prognosis was observed after SCLC transformation. Clinicogenomic analyses of paired and longitudinal samples identified genomic alterations emerging post-transformation and scRNA-seq reveal potential therapeutic targets in this population. Further studies are needed to rigorously validate biomarkers and therapeutic targets for this patient population

Successful thrombectomy of top-of-the-basilar artery occlusion - difficult to detect in clinical practice: A case report

Top-of-the-basilar artery occlusion frequently causes infarction of the midbrain, thalamus, and portions of the temporal and occipital lobes as the vascular supply of these regions comes from the posterior communicating and posterior cerebral arterial tributaries of the basilar artery. Clinical signs include an array of visual, oculomotor, and behavioral abnormalities, usually without prominent motor dysfunction, which makes diagnosis challenging for those inexperienced with these sign. We describe a 59-year-old male presenting with acute ischemic stroke due to top-of-the-basilar artery occlusion. Despite attempting several paraclinical examinations relating the sudden coma with Glasgow Coma Scale of 6 points, the neuroimaging detected the large vessel occlusion that was difficult to recognize. After confirming top-of-the-basilar artery occlusion, the recanalization was realized immediately. The patient was discharged with good clinical recovery